Involving patients and the public in developing STPs

In my work life I am a senior leadership consultant at The King’s Fund; however like all of us I am also a citizen in my community, and I am writing here from both perspectives.

In my local area over the past few weeks, I have heard quite a few people talking about the same thing – that is a recent article in the local paper stating that three major departments in our hospital are to be moved to the regional hospitals 50 to 60 miles away. As it turned out, the source of this story was proposals in our local sustainability and transformation plan (STP) which had been leaked to the press. This has caused a good deal of concern locally, with many people feeling fearful, confused and angry.

The experience of patients and public in my community is not unusual. Our recent report concludes that while STPs offer the best hope for delivering long-term improvement in health and social care, they have been beset by problems so far – including a lack of time to adequately include clinicians, frontline staff, patients and the public.

An NHS communication earlier this year to all leaders involved in developing STPs stressed that the plans are not an end in themselves, but rather a means to build and strengthen local relationships, enabling a shared understanding of where we are now, our ambition for 2020 and the steps needed to get there.

So what needs to happen if we are to meaningfully include patients and the public in the STP development process in future?

I think a clue lies in the word ‘meaningful’. I believe it would be helpful if it was made absolutely clear by those leading the STP process how patients and the public (and other stakeholders) are to be involved. In my opinion this would require a choice: either employ traditional approaches to engagement with their focus on gathering evidence and data about people’s experiences using feedback mechanisms and representational structures (with their flaws and underlying assumptions about roles and responsibilities across professional and citizen boundaries); or work towards what the NHS five year forward view describes as a ‘new relationship’ with patients, citizens and communities. At The King’s Fund we have defined this as a ‘collaborative relationship’ rather than a ‘them and us’ relationship.

A focus on collaborative and relational practices will involve a genuine commitment to sharing power, developing the values, principles and practices associated with dialogue and co-productive working, and potentially challenging current mindsets and established working cultures. These are issues we have been exploring with patients, citizens, clinicians and managers on our ’collaborative pairs’ programme. And earlier this year we published Patients as partners, which sets out a practical framework for developing collaborative relationships among NHS, patients and community partners.

I understand that those leading the STP development process are currently having to manage conflicting demands and work pressures, and also deliver to incredibly tight deadlines. However, the danger is that under this pressure people can retreat into their professional and organisational silos and adopt practices that maintain control, rather than work towards change for the better.

I wonder what would happen if people were prepared to challenge their assumptions around how patients and the public might react if given full disclosure? It might feel like a risk, but in my opinion it is just a new way of working that feels risky because of the shift in power, control, identity and knowledge; in fact the risks of not doing so could be even greater. What might happen if a different conversation was initiated, involving local communities coming together with the leaders of local health and care services to engage in a dialogue about opportunities?

Yes, this might be challenging. It will certainly confront existing assumptions held by all groups about how others might react when they come together. It will also generate different ways of looking at our current dilemmas, potentially enabling us to see new ways forward. I am certain there are readers of this blog who will have their own examples of local initiatives where citizens, patients, voluntary/third sector organisations and statutory providers have come together in different and innovative ways to find a solution for a local health and care issue.

I believe it is now incumbent on the leaders involved in the STP development process to model the ethos and practice of collaborative and partnership-working, with its focus on dialogue and relationship building. This is not fundamentally a question of time or resources (although of course these are important factors) – for me it is a question of attitude, of will and of courage – and a mindset prepared to confront the need for change in our working culture in order to achieve the health care service we need and want.

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#548740 Maggie Matthews
Patient//Lay member of CCG and Healthwatch Staffordshire
North Staffs CCG and Healthwatch Staffordshire

I find the updates from the Kings Fund really useful and informative and as a Patient representative on many groups the updates keep me and colleagues informed

#548742 Ian Scott
Patient rep, Community Health Ambassador

Very much concur with the previous post. I find Kings fund information extremely useful evidencing data and activities I use in my roles here in North East Hampshire.

#548743 phil strong
Health and social care products designer
Ergo Ike Ltd

Mark. An awfull amount of managing out and large amount of managing in, is required before this initiative has any chance of succeeding. Any hing less is like trying to platt fog IMO.
The present system is not fit for purpose in design, manpower and purpose.
The proposed STP is fundamentally flawed for a number of reasons.
It is politically led.
Heavily relying on the personell and thinking that have contributed greatly to the mess it is presently in.
The identified Sustainability is continuing to rely on human behaviour that historical research has shown time after time is unreliable,non compliant and unsustainable."continue doing what you have always done your gonna ge what you always got"-insanity, Albert Einstein.
Design the problems out by yes the end user leading the change and investing in new thinking, doing and technology.Try "Double Loop Learning"

#548755 Pearl Baker
Independent Mental Health Advocate and Advisor/Carer/ Trust Governor

To put what has been said in simple terms is easy, however to ever make progress for Patients and Carers, there has to be an understanding that everybody should be 'singing from the same hymn sheet' I do mean those responsible for making these changes for the 'GOOD' of all. Health and Social Care providers (locally) do exactly what they want, depending on their financial situation. West Berkshire Council have decided to separate the delivery of Health and Social Care? no 'joined' up thinking here. The consequences of the is for all to see. 'Care Plans' for those under Section 117 the most 'vulnerable' are no longer. 'Statutory Guidance' ignored including 'Safeguarding'. LA Deputy's for those subject to a COP Order for 'Property and Finance' are abusing their powers by 'IGNORANCE'. Charging for services that should be FREE is common place.

Transformation & Sustainability as far as I am concerned means nothing for me or those I support, everything is even more disjointed based on this LA decision to separate the delivery of Health & Social Care in isolation of HEALTH.

As an Advocate you need information to work from for your client! I no longer have a direct link to any agency to support either the Carer or Client. The LA will always answer in the following 'manner' we will reply in fifteen days? then it could be another fifteen days? or 'you need to refer to the GP? who then will not answer immediately either. 'Safeguarding' means absolutely nothing to anybody in West Berkshire, we are living in a 'FOG' of despair.

#548756 Pearl Baker
Independent Mental Health Advocate and Advisor/Carer/ Trust Governor

Please be advised I resigned my position as Governor of West Berkshire Priority care service NHS Trust for the following reasons: I was NOT allowed to take any complaints or concerns from the General Public and was instructed to refer onto PALs. My invitation to apply to become a Governor of this Trust was probably to keep me quiet.

#548757 Maurice Neville
Borough Councillor

The public engagement element, along with all other major elements of our local STP, is assessed as high risk in the STP document which has just been published. This is exacerbated by the fact that none of the back up documents on finance or workforce planning etc have been published. There is no timescale for any aspect of the public engagement process. This is a rolling PR disaster for all organisations involved, including the Councils

#548759 Bryan Hall
Retired SCDCllr,vol chair of local Integrated Health & Social Care Partnership.
Wickham Mkt Integrated Health & Social Care Hub & Partrnership

I heartily concurr with Marks comments. I have been working as (Vol)for over 3 years to provide a Social Care Hub in conjunction & Partnership with a helpful and sympathetic Professional Care Co,and the Health Centre & the 6 Vol Groups in my Village area,eg, Good Neighbours,Respite & Care Volunteers, Befrienders, British Legion Welfare, Community Skills Training Group, First Aid Team, including a combined 32 groups/orgs in support.(from across our catchment)
We have involved 2 former Health Ministers,SCC/ACS/ESCCG/NSFT etal, all have been supportive in principle,but with nhs/ACS staff changes, County Wellbeing Board Cllr changes it has been a slow process.Not least it took nearly a year from successfully bidding for a recent closed former SCC Care Home for the final property transfer to take place. This will provide 8/10 new reablement beds,plus residental & nursing care,plus a new Community run Social Care Club,for up to 12 residents/clients per day. Multiply this project across the UK and it would relive many Acute Hospital beds. My community has a marvellous record of Community Volunteering but it has not been easy to join the loose ends up of CCG/NHS/SCC/ACS budgets, so as to embrace & support this level of volunteering, and I suspect will be some
time before the wheels are better oiled.

#548763 john kapp

Well said, Mark, I agree with every word. I am trying ti get my HWB and CCG in Brighton and Hove to work together on a recovery plan (as we are the worst in the country, with both our CCG and hospital inadequate and 6 surgeries closed. I have proposed a conference next year inviting the leads to speak for 10 minutes each (as Kings Fund conferences) I would like to engage further about this approach to getting change without tears. Contact me on, or 01273 417997.

#548766 Jane Lodge
Head of Engagement
Brighton & Hove CCG

Great points Mark, and very true. We are in the situation where patients, carers and the public both want and need to be "engaged" and I am chomping at the bit to do it, in ways that you describe. BUT...... it's a waiting game for the agreed STP to emerge. In the meantime, we are carrying on with our local place based engagement work, broadening our reach and ensuring that we seek- as far as we can- collaborative solutions for local issues. We also need to accept when things are out of our hands - whether for the short or long term!

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